Livlife Home Health, Inc.

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs), for Comprehensive Assessment (a patient-specific, interdisciplinary evaluation conducted by a registered nurse (or qualified therapist) to determine a patient’s medical, nursing, rehabilitative, and social needs), of Patients as follows: 1. The HHA failed to assess the continuing need for home care services of three of seven sampled patients (Patient 1, Patient 2, and Patient 7). (Refer to G532). This deficient practice resulted in the provision of the unnecessary home health services to the patients who did not need skilled nursing services. 2. The HHA failed to review all the medications and update the medication profile with currently used medications for one of seven sampled patients (Patient 5). (Refer to G536). This deficient practice had the potential to put Patient 5 at risk for medication errors and adverse drug reactions. The cumulative effect of these systemic practices resulted in the failure of the home health agency to deliver statutorily mandated compliance with Federal regulations for Comprehensive Assessment of Patients to ensure home health benefits and services were furnished in accordance with accepted standards of practice.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency ((HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Care Planning, Coordination of Services, and Quality of Care as follows: Findings: 1. The HHA failed to provide home health services as indicated in the plan of care (POC, a detailed, written document outlining the services and support an individual’s needs to meet their healthcare goals), for two of seven sampled patients (Patient 2 and Patient 5). For Patient 2, the HHA failed to implement interventions and reassessment for pain management. For Patient 5, the HHA did not monitor the blood sugar as indicated in the POC. This failure has the potential to result in ineffective pain management for Patient 2, and inadequate blood sugar monitoring for Patient 5. (Refer to G572). 2. The HHA failed to include interventions for the patient’s specific goal of being able to perform daily activities without fatigue for one of seven sampled patients (Patient 5). This failure resulted in the patient not receiving necessary services, that could lead to delay and not meeting the patient’s goals. (Refer to G574). 3. The HHA failed to notify the physician promptly of their change in condition for one of seven sampled patients (Patient 3). This failure had the potential to result in patients not receiving care and treatment that could affect the patient’s health and well-being. (Refer to G590). 4. The HHA failed to notify the patients’ attending physician regarding their discharge needs and obtain discharge order at discharge for one out of two sampled discharged patients (Patient 3). This deficient practice resulted in an incomplete and inaccurate discharge information that reflects the patients’ current health status at discharge, and the potential that patients’ discharge planning needs were not identified, and the patients’ plan of care were not communicated to the attending physician. (Refer to G602). 5. The HHA failed to provide education to the patients and their family member on contaminated waste disposal to prevent injury and the spread of infection to one of seven sampled patients (Patient 5). This failure resulted in Patient 5 and her family member/caregiver being exposed to risk of injury and bloodborne pathogens. (Refer to G610). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Care Planning, Coordination of Services and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to provide home health services as indicated with the plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals), for two of seven sampled patients (Patient 2 and Patient 5). For Patient 2, the HHA failed to ensure that interventions and reassessment for pain for pain management.. For Patient 5, the HHA did not monitor the blood sugar per the POC. This failure has the potential to result in ineffective pain management for Patient 2, and inadequate blood sugar monitoring for Patient 5. Findings: a. During a review of Patient 2’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/17/2025. During a review of Patient 2’s POC for the certification period starting from 12/15/2025 to 2/12/2026, and for the certification period from 2/13/2026 to 4/13/2026, the POC indicated Patient 2 had a diagnosis that included essential hypertension (high blood pressure), hyperlipidemia (a condition characterized by abnormally high levels of fats in the blood), and generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control). The POC included an order for the registered nurse (RN) or the licensed vocational nurse (LVN) to visit Patient 2 once a week for 9 weeks for skilled nursing assessment, monitoring of vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse (heart rate) and respiratory [breathing] rate), and to assess pain level on a scale of 0-10 (0 = no pain, 10 = unbearable pain), implement pain relief measures and evaluate effectiveness. During a concurrent interview and record review, on 3/20/2026 at 10:45 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 2’s Nursing Visit Record dated 1/31/2026 and 3/16/2026. The ADM/DPCS stated the Nursing Visit Record dated 1/31/2026 and 3/16/2026 indicated Patient 2 was experiencing pain 4 out of 10 to her lower back and multiple joints and there was no documented evidence pain intervention was provided, nor a follow-up pain reassessment was performed to Patient 2. The ADM/DPCS stated completed pain management on every skilled nurse visit should include pain intervention that was implemented if patient experiencing pain and the effectiveness of the intervention. The ADM/DPCS stated and acknowledged that in the case of Patient 2, it was not done. The ADM/DPCS stated it was important to reassess pain after pain intervention to determine treatment effectiveness and ensure patient safety. b. During a review of Patient 5’s POC for the certification period of 2/9/2026 to 4/9/2026, the POC indicated that Patient 5 was admitted to the HHA on 12/11/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated that Patient 5 was to receive Registered Nurse (RN)/Licensed Vocational Nurse (LVN) visit once a week for nine weeks. The POC indicated the visiting nurse would be responsible to test the patient’s blood glucose every visit and to teach the patient the importance of recording blood sugar reading. The nurse would need to notify the physician if the patient’s blood glucose was below 60 mg/dl (milligrams per deciliter, a unit measurement) or above 350 mg/dl. During a joint home visit observation on 3/18/2026 at 1:30 p.m., with LVN 1 at Patient 5’s residence, observed Patient 5 awake, alert, and oriented. Observed Patient 5 walking with a walker (a portable, four-legged metal frame medical device that provides stability and support for people with mobility issues, weaknesses, or balance problems). A family member of Patient 5 (FM 2) was present during the joint home visit. During an interview with FM 2 on 3/18/2026 at 2 p.m., the surveyor asked FM 2 if Patient 5 kept a log of her blood sugar readings. FM 2 stated that there was no blood sugar log for Patient 5. According to FM 2, Patient 5 was able to check her own blood sugar, but she (Patient 5) did not record it. FM 2 stated that Patient 5 had not checked her blood sugar that day. LVN 1 proceeded to check Patient 5’s blood sugar. Patient 5’s random blood sugar was 127 mg/dl. During an interview with LVN 1 on 3/18/2025 at 2:20 p.m., LVN 1 stated that the visiting nurse needed to check Patient 5’s blood sugar per plan of care. LVN 1 stated that he did not know Patient 5’s blood sugar range as he had never visited Patient 5 before. On 3/20/2026, at 9:01 a.m., the surveyor made a telephone call to interview LVN 2 (who had been visiting Patient 5 weekly). The call was not answered or returned. During a concurrent interview and record review with the ADM/DPCS on 3/20/2026 at 12:27 p.m., the ADM/DPCS reviewed Patient 5’s POC for the certification period of 2/9/2026 to 4/9/2026 and Nursing Visit Records dated 2/12/2026, 2/20/2026, 2/26/2026, 3/5/2026, and 3/11/2026. The ADM/DPCS stated that only Nursing Visit Records indicated that Patient 5’s blood sugar was checked during the home visit, but the blood sugar reading was not recorded. The ADM/DPCS stated the rest of the Nursing Visit Records did not indicate if blood sugar was checked or not, and there were no blood sugar readings documented. The ADM/DPCS acknowledged that the HHA had not been monitoring Patient 5’s blood sugar. The ADM/DPCS stated that without monitoring, the HHA did not know if Patient 5’s blood sugar was within the expected range. During a review of the HHA’s Policy and Procedure (P&P), titled “Care Planning Process,” revised April 2018, the P&P indicated a written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved. During a review of the agency’s P&P titled Pain Assessment, revised April 2018, the P&P indicated all patients will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity using a rating scale (on a scale of 0 – 10: 0=no pain; 10=unbearable pain), pain location, quality, onset, duration, alleviating and aggravating factors, and present pain management regimen and effectiveness. During a review of the agency’s P&P titled Pain Management, revised April 2018, the P&P indicated the patient’s right to pain management is respected and supported. Health care clinicians plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately. Pain will be assessed as a part of every patient contact if the patient reports pain or is at risk for pain. Patients who report pain will receive further assessment and appropriate management.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure appropriate contaminated sharps disposal for one of seven sampled patients (Patient 5). This deficient practice had the potential to expose patient and/or caregiver to infection caused by blood-borne pathogens from contaminated sharps. Findings: During a review of Patient 5’s Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period of 2/9/2026 to 4/9/2026, the POC indicated that Patient 5 was admitted to the HHA on 12/11/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated that Patient 5 was to receive Registered Nurse (RN)/Licensed Vocational Nurse (LVN) visit once a week for nine weeks. The POC indicated the visiting nurse was responsible to instruct patient on infection control measures and proper disposal of sharps. Per POC, the HHA was to provide sharp disposal container. During a joint home visit observation on 3/18/2026 at 1:30 p.m., with LVN 1, at Patient 5’s residence, observed Patient 5 awake, alert, and oriented. Patient 5 was observe walking with a walker (a portable, four-legged metal frame medical device that provides stability and support for people with mobility issues, weakness, or balance problems). A family member of Patient 5 (FM 2) was present during the joint home visit. During the joint home visit, on 3/18/2026 at 1:30 p.m., a medication review was performed with LVN 1 and an interview with FM2. Patient 5 was taking Mounjaro (weekly injectable medication to improve blood sugar control in adults with type 2 diabetes) injections once a week. FM 2 stated that she administered the weekly Mounjaro injections for Patient 5. When FM 2 was asked to show the sharps disposal container (a heavy-duty, puncture-resistant, and leak-proof container designed for the safe disposal of needles, syringes, lancets, and other sharp medical instruments) to the surveyor, FM 2 stated, “We don’t have one. We don’t need it because after I give the injection, the needle is always covered, it’s okay.” FM 2 stated she disposed the used needle in the trash can. During an interview with LVN 1 on 3/18/2026 at 2:20 p.m., LVN 1 stated that used needles needed to be disposed of in a sharps container for safety and infection control purposes, even though the needle was not exposed. During an interview with the Administrator/Director of Nursing Care Services (ADM/DPCS) on 3/19/2026 at 10:43 a.m., the ADM/DPCS stated that used needles and/or lancets should not have been thrown away in a trash can as they could present a risk for injury and spread of infection. During a review of the HHA’s Policy and Procedure (P & P), titled “Contaminated Waste Disposal,” revised April 2018, the P & P indicated that needles, syringes, and razor blades should be placed in a puncture-proof container and labeled as contaminated waste when ¾ full.”

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to assess the continuing need for home care services for three of seven sampled patients (Patient 1, Patient 2, and Patient 7). This failure resulted in the provision of the unnecessary home health services to the patients who did not need skilled nursing services. Findings: a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 6/6/2025. During a review of Patient 1’s Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home), for the certification period of 8/5/2025 to 10/3/2025, the POC indicated Patient 1 had a diagnosis that included essential hypertension (high blood pressure), hyperlipidemia (a condition characterized by abnormally high levels of fats in the blood), and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). The POC included an order for the registered nurse (RN) or the licensed vocational nurse (LVN) to visit Patient 1 once a week for 9 weeks for skilled nursing assessment, monitoring of vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), management of medications/pain, patient and/or patient caregiver (PCG) education on disease process and to report to primary medical doctor (PMD) any negative outcomes. The POC goal indicated Patient 1 will be free of any falls/injuries/hospitalizations, blood pressure will be within physician established parameters, will not have any evidence of skin breakdown, will demonstrate compliance with medication, and patient and patient caregiver will demonstrate competence in following medical regimen. The discharge planning indicated to discharge Patient 1 when goals are met, when medical condition is stable, and patient is no longer in need of skilled services. During a joint home visit, on 3/18/2026 at 12:20 p.m., at Patient 1’s residence with the licensed vocational nurse (LVN 1), Patient 1 was observed awake, alert, oriented x 2 (to person and place), and ambulatory accompanied by a caregiver (CG 1). Patient 1 was observed with no wounds, and has no medical line catheters (thin, flexible tubes inserted into the body to deliver fluids, medication, nutrition, or to drain fluids like urine). During an interview with CG 1, on 3/18/2026 at 12:36 p.m., CG 1 stated Patient 1’s blood pressure was within normal range, pain was controlled with medications, had no falls, no recent hospitalization, no wound treatment, on regular diet, and goes to his physician’s appointment regularly. During a concurrent interview and record review, on 3/20/2026 at 11:05 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 1’s OASIS (or Outcome and Assessment Information Set, a standardized, comprehensive assessment tool used in home health care to evaluate adult patient clinical/functional status) Nurse Recertification form (a mandatory, comprehensive assessment conducted every 60 days to evaluate a patient’s continued need for services, update their plan of care, and determine ongoing Medicare payment) dated 10/2/2025, and Nursing Visit Records for the month of September 2025 were reviewed with ADM/DPCS. The ADM/DPCS stated Patient 1 had no recent hospitalization, no falls, no wound care treatment performed, vital signs were within normal range, and had no documented evidence of signs and symptoms of hypertension, like headaches, dizziness, chest pain, heart palpitations (a pounding sensation in the chest, neck, or ears), or vision changes. The ADM/DPCS stated Patient 1 was recertified for multiple 60 days of continuous skilled nursing services. b. During a review of Patient 2’s Face Sheet, the Face Sheet indicated a start of care date of 8/17/2025. During a review of Patient 2’s POC for the certification period starting from 10/16/2025 to 12/14/2025, the POC indicated Patient 2 had a diagnosis that included essential hypertension, hyperlipidemia, and generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control). The POC included an order for the RN or the LVN to visit Patient 2 once a week for 8 weeks for skilled nursing assessment, monitoring of vital signs, and to assess pain level on a scale of 0-10 (0 = no pain, 10 = unbearable pain), implement pain relief measures and evaluate effectiveness. The POC goal indicated Patient 2 will be free of any falls/injuries/hospitalizations, blood pressure will be within physician established parameters, will not have any evidence of skin breakdown, will demonstrate compliance with medication, and patient and patient caregiver will demonstrate competence in following medical regimen. The discharge planning indicated to discharge Patient 2 when goals are met, when medical condition is stable, and patient is no longer in need of skilled services. During a joint home visit, on 3/18/2026 at 1:55 p.m., at Patient 2’s residence with the ADM/DPCS, Patient 2 was observed awake, alert, and oriented x 3 (to person, place and time), accompanied by a family member (FM 1). Patient 2 was observed with no wounds, and had no medical lines or catheters. During an interview with FM 1, on 3/18/2026 at 2:12 p.m., FM 1 stated Patient 2’s takes his medications regularly, goes visit his physician regularly, had no falls, no recent hospitalization, no wound treatment, and doing fine. During a concurrent interview and record review, on 3/20/2026 at 11:08 a.m., with the ADM/DPCS, Patient 2’s OASIS Nurse Recertification form dated 12/12/2025, and Nursing Visit Records for the month of November 2025 and December 2025 were reviewed by the ADM/DPCS. The ADM/DPCS stated Patient 2 had no recent hospitalization, no falls, no wound care treatment performed, vital signs were within normal range and had no documented evidence of signs and symptoms of hypertension like headaches, dizziness, chest pain, heart palpitations, or vision changes. However, the ADM/DPCS stated Patient 2 was recertified for multiple 60 days of continuous skilled nursing services. The ADM/DPCS stated once patient goals have been met or unattainable, and have no more skilled nursing needs, patients should be discharged from home health service. c. During a review of Patient 7’s Plan of Care/POC for the certification period of 11/16/2025 to 1/14/2026, the POC indicated that Patient 7 was admitted to the HHA on 9/17/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) without complications. The POC indicated the patient-centered goal for Patient 7 was stable blood sugar to avoid complications. The POC indicated that the physician notification parameters for blood glucose were below 60 milligrams per deciliter, (mg/dl a unit measurement) or above 350 mg/dl. During a review of Patient 7’s Nursing Visit Records for the certification period of 11/16/2025 to 1/14/2026, the data for Patient 7’s random blood sugar (glucose levels in a non-fasting person at any time of day, regardless of when they last ate) was as follows: 11/22/2025: 160 mg/dl11/29/2025: 156 mg/dl12/6/2025: 164 mg/dl12/13/2025: 158 mg/dl12/20/2025: 170 mg/dl12/27/2025: 170 mg/dl1/3/2026: 178 mg/dl1/10/2026: 174 mg/dl Patient 7 had a recertification assessment done on 1/13/2026. Patient 7 was recertified to receive home health services for another certification period (60 days). During a review of Patient 7’s Plan of Care/POC for the certification period of 1/15/2026 to 3/15/2026, the POC indicated the patient-centered goal for Patient 7 was absence of diabetic complications and high blood sugar levels (hyperglycemia). The POC indicated that the physician notification parameters for blood glucose were below 60 mg/dl or above 350 mg/dl. During a review of Nursing Visit Records for Patient 7 for the certification period of 1/15/2026 to 3/15/2026, the data for Patient 7’s random blood sugar was as follows: 1/24/2026: 150 mg/dl1/31/2026: 158 mg/dl2/7/2026: 160 mg/dl2/14/2026: 170 mg/dl2/21/2026: 174 mg/dl2/28/2026: 152 mg/dl3/7/2026: 164 mg/dlPatient 7 had a recertification assessment done on 3/14/2026. Patient 7 was recertified to receive home health services for another certification period (60 days). During a telephone interview with Patient 7 on 3/18/2026 at 12:07 p.m., Patient 7 stated she had been visited by a home health nurse for a few months. Patient 7 stated she was referred to the HHA by her physician to ensure that her blood sugar was under control. Patient 7 stated her blood glucose levels had been well controlled since she took Mounjaro (weekly injectable medication to improve blood sugar control in adults with type 2 diabetes) injection once a week. Patient 7 stated, “I used to have pain in my feet, and my blood sugar was high before I took Mounjaro. Now my blood sugar is very good and the pain is gone. I feel good.” Patient 7 stated she did her own Mounjaro injections. When Patient 7 was asked if Mounjaro was recently prescribed, Patient 7 stated that she had been on Mounjaro for a while. During a review of Patient 7’s Medication Profile, the Medication Profile indicated that Patient 7 has the medication Mounjaro upon admission on 9/17/2025. During a concurrent interview and record review with the ADM/DPCS on 3/20/2026 at 11:38 a.m., the ADM/DPCS reviewed Patient 7’s POC for the certification period of 11/16/2025 to 1/14/2026 and Nursing Visit Records dated 11/22/2025, 11/29/2025, 12/6/2025, 12/13/2025, 12/20/2025, 12/27/2025, 1/3/2026, and 1/10/2026. The ADM/DPCS stated that Patient 7’s blood sugar was stable and there were no complications by the end of the second certification period (1/14/2026). The ADM/DPCS reviewed Patient 7’s POC for the certification period of 1/15/2026 to 3/15/2026 and Nursing Visit Records dated 1/24/2026, 1/31/2026, 2/7/2026, 2/14/2026, 2/21/2026, 2/28/2026, and 3/7/2026. The ADM/DPCS stated that Patient 7’s blood sugar remained within the parameters throughout the certification period and there were no complications. The ADM/DPCS stated that despite Patient 7’s blood sugar levels falling within appropriate parameters since the end of the second certification period (1/14/2026), Patient 7 was recertified to continue receiving home health services. During a review of the agency’s policy and procedure (P&P) titled, “Discharge Criteria and Process,” revised April 2018, the P&P indicated when the patient’s plan of care changes and this change results in discharge or reduction of services, the patient or his/her representative, as well as his/her primary physician, will be notified and involved in planning decisions. Services will be terminated when the patient meets one or more of the discharge criteria: if appropriate, the goals of home health have been attained or are no longer attainable.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to review all the medications and update the current medication profile (is a comprehensive, up-to-date record of a patient’s current medications, including dosage, frequency, route, and prescribing physician), with currently used medications for one of seven sampled patients (Patient 5). This deficient practice had the potential to place the patients at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 5’s Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period of 2/9/2026 to 4/9/2026, the POC indicated Patient 5 was admitted to the HHA on 12/11/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated Patient 5 was to receive Registered Nurse (RN)/Licensed Vocational Nurse (LVN) visit once a week for nine weeks. Patient 5’s POC indicated that the visiting nurse would be responsible for medication management, such as pill box, calendar, and weekly medication set-ups. The visiting nurse would be responsible for providing medication teaching or instructions, such as medication actions, uses, frequency, dose, side effects, and interactions. During a joint home visit observation on 3/18/2026 at 1:30 p.m., with LVN 1 at Patient 5’s residence, observed Patient 5 awake, alert, and oriented, walking with a walker (a portable, four-legged metal frame medical device that provides stability and support for people with mobility issues, weakness, or balance problems). A family member of Patient 5 (FM 2) was present during the joint home visit. During a concurrent observation, and record review, on 3/18/2026 at 1:52 p.m., with LVN 1, observed Ibandronate Sodium (medication used to treat and prevent osteoporosis [a bone disease that weakens bones, making them porous, less dense, and more likely to fracture] in postmenopausal women, helping to increase bone density and reduce spine fractures) 150 mg (milligram, a unit measurement). The instruction was written in the Farsi (Persian) language. According to LVN 1 and FM 2, who could read and write Persian alphabets, the instruction read, “Take one tablet by mouth monthly.” Patient 5’s Medication Profile for the certification period of 2/9/2026 to 4/9/2026 indicated that the frequency for Sodium Ibandronate 150 mg was one tablet daily. Patient 5’s Medication Profile listed Carboxymethylcellulose Sodium 1% (artificial tears to relieve dry, irritated eyes), one drop into both eyes daily. The eye drop was not found at Patient 5’s home. During an interview on 3/18/2026 at 2:15 p.m., with FM2, FM 2 stated that Patient 5 took Sodium Ibandronate once a month, not once a day. FM 2 stated that Carboxymethylcellulose Sodium 1% eye drop was discontinued by the physician at the end of 2025. During an interview with LVN 1 on 3/18/2025 at 2:20 p.m., LVN 1 stated medication reconciliation needed to be done to make sure the patient had an updated medication list. LVN 1 stated the nurse needed to check the patient’s medications with every visit. During an interview on 3/19/2026 at 10:43 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS stated that if a medication was discontinued by the physician, then the visiting nurse needed to update the patient’s medication profile. The ADM/DPCS stated that Ibandronate Sodium was a monthly medication, not daily. The Adm/DPCS stated it was important that patients had an accurate and updated medication profile to ensure that patients took the correct medications and followed the correct dose and frequency. During a review of the HHA’s Policy and Procedure (P & P), titled “Medication Profile,” revised April 2018, the P & P indicated that medication profiles would be updated for each change to reflect current medications and new and/or discontinued medications.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to include interventions for the patient’s specific goal of being able to perform daily activities without fatigue for one of seven sampled patients (Patient 5). This deficient practice had a potential for patient not receiving necessary services, which may delay the patient from achieving her healthcare goals. Findings: During a review of Patient 5’s Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period of 2/9/2026 to 4/9/2026, the POC indicated that Patient 5 was admitted to the HHA on 12/11/2025 with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar) with hyperglycemia (high blood sugar). The POC indicated that the patient-centered goals for Patient 5 were to maintain stable blood pressure and to perform daily activities without feeling fatigued. The POC indicated that Patient 5 was to receive Registered Nurse (RN)/Licensed Vocational Nurse (LVN) visit once a week for nine weeks. There were no other disciplines ordered besides nursing. During a joint home visit observation on 3/18/2026 at 1:30 p.m., with LVN 1, at Patient 5’s residence, observed Patient 5 awake, alert, and oriented. Patient 5 was observe walking with a walker (a portable, four-legged metal frame medical device that provides stability and support for people with mobility issues, weakness, or balance problems). A family member of Patient 5 (FM 2) was present during the joint home visit. During an interview with FM 2 on 3/18/2026 at 2 p.m., FM 2 stated that Patient 5 had never received therapy from the HHA. When FM 2 was asked if the HHA had offered therapy services for Patient 5, FM 2 stated, “No.” FM 2 stated that therapy might help Patient 5 get stronger. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 3/20/2026 at 12:27 p.m., the ADM/DPCS reviewed Patient 5’s POC for the certification period of 2/9/2026 to 4/9/2026. The ADM/DPCS stated that she believed that Patient 5 would benefit from receiving physical therapy. The ADM/DPCS stated that currently the HHA did not have interventions to achieve Patient 5’s goals of improving physical endurance. During a review of the HHA’s Policy and Procedure (P & P), titled “Care Planning Process,” revised April 2018, the P & P indicated that the care planning decisions would be reflected in the specific services that would be provided and the associated actions planned and implemented to meet individualized patient problems and goals.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to notify the patient’s physician for a change of condition for one of seven sampled patients (Patient 3). This deficient practice had the potential to result in Patient 3 not receiving the proper care and treatment which could affect the patient’s health and well-being. Findings: During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 6/3/2025. During a review of Patient 3’s Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for the certification period starting from 11/30/2025 to 1/28/2026, the POC indicated Patient 3 had a diagnosis that included chronic venous hypertension with ulcer (high pressure in leg veins causes blood pooling, edema, skin discoloration, and tissue breakdown in the lower leg) and inflammation of bilateral lower extremities, essential hypertension (high blood pressure), and non-pressure chronic ulcer of left and right calf (a long-lasting, slow-healing open sore below the knee) with fat layer exposed. The POC included an order for the registered nurse (RN) or the licensed vocational nurse (LVN) to visit Patient 3 three times a week for 8 weeks starting 11/30/2025 and twice a week for 1 week starting on 1/25/2025 for skilled nursing assessment, monitoring of vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse (heart rate) and respiratory [breathing] rate), perform wound care three times a week on patient’s left and right lower extremity wounds, and assess the site for signs and symptoms of deterioration of wound healing such as increase in size, diameter and depth with presence of foul-smelling purulent exudate, increase in swelling, redness and pain. During a phone interview, on 3/18/2026 at 10:29 a.m., with the licensed vocational nurse (LVN 3), LVN 3 stated that on 1/15/2026 skilled nurse visit, Patient 3’s left and right lower extremity wound was warm to touch and had increased in redness in the wound area. LVN 3 stated Patient 3’s left and right lower extremity wound had a change of condition on 1/15/2026 due to signs of infection and notified the Administrator/Director of Patient Care Services (ADM/DPCS). LVN 3 stated she did not notify Patient 3’s physician about the change in condition. During a concurrent interview and record review, on 3/20/2026 at 10:45 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 3’s Nursing Visit Record dated 1/15/2026. The ADM/DPCS stated LVN 3’s assessment of the patient’s wound on 1/15/2026 indicated a change of condition due to possible wound infection. The ADM/DPCS was unable to provide documented evidence Patient 3’s physician was notified of the change of condition of the patient’s wound on 1/15/2026. The ADM/DPCS stated that for a change of condition, it was important to notify patient’s physician right away for further instructions, enable early intervention and for patient safety. During a review of the agency’s P&P titled Monitoring Patient’s Response/Reporting to Physician, revised April 2018, the P&P indicated clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. The patient’s physician will be contacted on the same day when any of the following occur:.. changes in the patient’s condition.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence), failed to notify the patients’ attending physician regarding their discharge needs and obtain discharge order at discharge for one out of two sampled discharged patients (Patient 3). This deficient practice resulted in an incomplete and inaccurate discharge information of patients’ current health status at discharge, and the potential for patients’ discharge planning needs not identified, and were not communicated to the attending physician. (Refer to G602). Findings: During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 6/3/2025. During a review of Patient 3’s Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for the certification period starting from 11/30/2025 to 1/28/2026, the POC indicated Patient 3 had a diagnosis that included chronic venous hypertension with ulcer (high pressure in leg veins causes blood pooling, edema, skin discoloration, and tissue breakdown in the lower leg) and inflammation of bilateral lower extremities, essential hypertension (high blood pressure), and non-pressure chronic ulcer of left and right calf (a long-lasting, slow-healing open sore below the knee) with fat layer exposed. The POC included an order for the registered nurse (RN) or the licensed vocational nurse (LVN) to visit Patient 3 three times a week for 8 weeks starting 11/30/2025 and twice a week for 1 week starting on 1/25/2025. During a concurrent interview and record review, on 3/20/2026 at 10:45 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 3’s OASIS (or Outcome and Assessment Information Set, a standardized, comprehensive assessment tool used in home health care to evaluate adult patient clinical/functional status, guide care planning, and determine Medicare reimbursement ) Transfer/Death form dated 1/21/2026, and the physician order section of Patient 3’s electronic health record. The ADM/DPCS stated Patient 3 was discharged from home health service on 1/21/2026 due to being transferred to an inpatient facility. There was no documented evidence Patient 3’s attending physician was notified of the patient’s discharge needs, and the ADM/DPCS stated and confirmed no physician discharge order was found in the patient records. During a review of the HHA’s policy and procedure (P&P) titled Discharge Criteria and Process, revised April 2018, the P&P indicated when the patient’s plan of care changes and this change results in discharge from or reduction of services, the patient or his/her representative, as well as his/her primary physician, will be notified and involved in planning decisions. All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order, discharge summary, plan of care, medication profile, and OASIS.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to provide education to the patients and their family member on contaminated waste disposal to prevent injury and the spread of infection to one of seven sampled patients (Patient 5). This failure resulted in Patient 5 and her family member/caregiver being exposed to risk of injury and bloodborne pathogens Findings: During a review of Patient 5’s Plan of Care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals), for the certification period of 2/9/2026 to 4/9/2026, the POC indicated Patient 5 was admitted to the HHA on 12/11/2025, with a primary diagnosis of type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, leading to high blood sugar), with hyperglycemia (high blood sugar). The POC indicated that Patient 5 was to receive Registered Nurse (RN)/Licensed Vocational Nurse (LVN), visit once a week for nine weeks. The POC indicated the visiting nurse was responsible to instruct patient on infection control measures and proper disposal of sharps. Per POC, the HHA was to provide sharp disposal container. During a joint home visit observation on 3/18/2026 at 1:30 p.m., with LVN 1 at Patient 5’s residence, observed Patient 5 awake, alert, and oriented. Observed Patient 5 walking with a walker (a portable, four-legged metal frame medical device that provides stability and support for people with mobility issues, weakness, or balance problems). A family member of Patient 5 (FM 2) was present during the joint home visit. During an interview with FM 2 on 3/18/2026 at 2 p.m., FM 2 stated that she administered the weekly Mounjaro (weekly injectable medication to improve blood sugar control in adults with type 2 diabetes) injections for Patient 5. When FM 2 was asked to show the sharps disposal container (a heavy-duty, puncture-resistant, and leak-proof container designed for the safe disposal of needles, syringes, lancets, and other sharp medical instruments) to the surveyor, FM 2 stated, “We don’t have one. We don’t need it because after I give the injection, the needle is always covered, it’s okay.” FM 2 stated she disposed the used needle in the trash can. During an interview with LVN 1 on 3/18/2026 at 2:20 p.m., LVN 1 stated that used needles needed to be disposed of in a sharps container for safety and infection control purposes, even though the needle was not exposed. During an interview with the Administrator/Director of Nursing Care Services (ADM/DPCS) on 3/19/2026 at 10:43 a.m., the ADM/DPCS stated that when the nurse offered a sharps disposal container for Patient 7, FM 2 refused, stating, “It’s ugly.” The ADM/DPCS stated that used needles and/or lancets should not have been thrown away in a trash can as they could present a risk for injury and spread of infection. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on 3/19/2026 at 10:55 a.m., the ADM/DPCS reviewed Patient 5’s Nursing Visit Records dated 2/26/2026, 3/5/2026, and 3/11/2026. The ADM/DPCS stated that there was no documentation if the visiting nurse educated the patient and family member/caregiver regarding the importance of using a sharps container to dispose of used needles. During a review of the HHA’s Policy and Procedure (P & P), titled “Patient Education Process,” revised April 2018, the P & P indicated that education would be the responsibility of each clinician and would focus on: Facilitating the patient and family/caregiver’s understanding of his/her health status, health care options, and consequences of options.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to follow its discharge policy by not completing patient’s discharge summary within 72 hours of discharge from home health service, for one of two sampled discharge patients (Patient 3). This failure had the potential to affect the patient’s outcome and post discharge instructions. Findings: During a review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 6/3/2025. During a review of Patient 3’s Plan of Care (POC, a detailed, written document outlining the patient’s specific needs, including skilled nursing care, rehabilitative, and supportive care provided to a patient at home) for the certification period starting from 11/30/2025 to 1/28/2026, the POC indicated Patient 3 had a diagnosis that included chronic venous hypertension with ulcer (high pressure in leg veins causes blood pooling, edema, skin discoloration, and tissue breakdown in the lower leg) and inflammation of bilateral lower extremities, essential hypertension (high blood pressure), and non-pressure chronic ulcer of left and right calf (a long-lasting, slow-healing open sore below the knee) with fat layer exposed. The POC included an order for the registered nurse (RN) or the licensed vocational nurse (LVN) to visit Patient 3 three times a week for 8 weeks starting 11/30/2025 and twice a week for 1 week starting on 1/25/2025. During a concurrent interview and record review, on 3/20/2026 at 10:45 a.m. with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 3’s chart in the patient electronic health records. The ADM/DPCS stated Patient 3 was discharged from home health service on 1/21/2026 due to being transferred to another inpatient facility. However, the ADM/DPCS was unable to provide documented evidence that a discharge summary was completed and filed in the clinical record for Patient 3 within 72 hours of discharge. During a review of the HHA’s policy and procedure (P&P) titled Discharge Summary, revised April 2018, the P&P indicated each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. During a review of the HHA’s policy and procedure (P&P) titled Contents of the Clinical Record, revised April 2018, the P&P indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. The following information will be available in the clinical record, as applicable to care and services provided - discharge summary and other summary reports sent to the physician, as required by law, regulation, and organization policy.”